Inside Reproductive Health, Ep 22

Benefits and Barriers of International Fertility Care. An Interview with Lori Whalen, R.N.

In this episode, host Griffin Jones speaks to Lori Whalen, a RN who currently works at HRC in Southern California as the international IVF coordinator. Whalen speaks across the country about topics such as compassion fatigue, so Jones invited her to discuss the intricacies related to international IVF as well as the ways to combat the compassion fatigue that often accompanies this high-pressure field.

Griffin Jones: Today on Inside Reproductive Health, I’m joined by Lori Whalen. Lori is a registered nurse, she works at HRC, in Southern California. She’s the international IVF coordinator there, she has been the clinic manager at a number of different clinics, managed different nursing teams, speaks throughout the field at places like MRSI, at PCRS, at Serono’s Speakers Bureau as well as being a part of the nurses’ professional group in ASRM and other meetings hosted by educational pharmaceutical initiatives throughout the country… Lori Whalen, welcome to Inside Reproductive Health.

Lori Whalen: Thank you, Griffin, it’s really nice to be here!

GJ: So we’re actually recording this before PCRS. It’s gonna come out after PCRS. But let’s pretend we’re at the pool right now, having a cocktail with all of our colleagues and friends around us.

LW: *laughs* Awesome.

GJ: I really wanted to have you on because you’ve spoken at a number of different conferences, some of the same ones that I’ve spoken at, and we’ve been on panels together and been on the same dockets together, and I want to know how someone goes from being a nurse who some people don’t want to do one darn thing in addition to what they already have to do in the office to somebody who is talking about this in the field. Talk about the interest and why you feel interested in or compelled to do that.

LW: Well, I think that being a nurse first of all, we’re very diverse and I think it’s the need for information, and the need for learning. I had a need to learn more and be better at my trade, so that I could be better… a better nurse to be able to speak to my patients, to make them feel that I’m educated and that I know what I’m talking about. And when you can do that or have the confidence to do that, then your patients will learn to trust you a little bit more, and trust the information that you’re giving them. I think it really helps to take care of your patients at a different level. I know some people are not interested in learning anything more than they have on their plate, but sometimes it can make your job a little easier the more knowledge that you have under your belt, y’know, helps you feel more confident about the job that you’re doing .

GJ: Of all the topics that you speak on, what do you enjoy the most?

LW: I like to speak on compassion fatigue. Right now, being in the business for a long time, I think this is a really real problem for infertility nurses today. Whether you’ve been in for six years or you’ve been in for many years because it does affect your job performance, it affects your health, it affects everything about you as a person. You’re not able to do your job at a capacity at which you’d like to do your job, and so I think getting the word out there that this is a real thing that’s happening with nurses today, it goes beyond just burnout, today we have so much technology and so many other things we need to talk to patients about than we ever have before, so that puts a lot of burden on the nurses today on what we have to educate our patients about. You think about we have to do this with every single patient we come into contact with, and y’know we don’t always get the best responses from patients and no matter how hard we try or how much time we spend with patients, they still they come at us with… that they are not appreciative of the information that we’re giving them and that’s really a hard thing for us to try to manage.

GJ: So how do you go from being clinical manager dealing with these issues on a day-to-day basis and speaking to compassion fatigue to the international side of things, tell us about how that happened.

LW: I think that being a part of the international group became because we do a lot of gender selection in our office, so going from doing third party and then managing local patients that you just basic patients for what you see and even the basic patients who have genetic issues or things like that, those are hard patients to manage as well, but going into international, with gender selection, it’s out there, it’s all over the world, where it’s very restrictive or it’s against the law, that’s how I became part of that process. And it is a lot, it’s like dealing with third party people all over the world. You have to organize everything for these patients that are coming from another country, trying to stay close to them, getting them all the information that they need to in a timely manner, with the time differences from everywhere, sometimes you go crazy not knowing where you’re at in the world as far as timing goes. It’s very interesting, you meet interesting people, but it is very stressful, it’s just as stressful doing that as any other part of any fertility… people that you have to deal with. Third party, regular patients, I say regular patients andI mean the ones that are local, that are pretty basic, but they have a lot of emotional needs as well. That doesn’t change with any patient that comes from any part of the world. I enjoy it, it is kind of now my forte that I’m known for, and I like it, but with it comes a lot of stress and trying to handle employees as well with their stress, it’s a lot.

GJ: I imagine that it’s like being a third party coordinator on steroids, for those that are unfamiliar, in certain countries, maybe like Japan, China, among others, Australia, New Zealand, sex selection is illegal, using PGT for sex selection in those countries is typically against the law, so they come ot a place like California. Is that right?

LW: Yeah, so, in the United States, gender selection is legal, however, that doesn’t mean that all clinics are going to provide that service, because there is some ethical issues that people feel that involves gender selection, so they choose not to offer it at their clinics, which is totally fine, I get that. I had that issue in the beginning, but I had to realize that I’m not the one to be judging these patients or people for what they wanna do, I’m here to provide a service. And I hope to give them the best care that they deserve going through with that.

GJ: And you can mention, some clinics are doing it — there’s such a demand for it, some clinics are doing it at such a volume where that’s your full-time job, being the international IVF coordinator. Is it all sex selection and a lot of countries don’t allow for either egg donor or gestational carrier, or they just have very strict rules for compensation for it, so they have very few, and folks need to come to the United States. Is there donor egg and gestational carrier needs as well, or is it almost entirely sex selection?

LW: Well, yeah, so they some patients that are doing sex selection are also using a surrogate. We find a lot of our Chinese patients do that, just using a surrogate in general, freezing their eggs and using a surrogate. But yeah, we have a lot of patients that are doing gender selection as well.

GJ: How do you describe the differences in managing this patient load, this case load versus other types of cases? You said you’re dealing with similar issues, they have the same needs at the end of the day, I imagine by virtue of things like thousands of miles of travel, there’s an additional stress component. But how do you describe the differences between third party patients that are coming to you locally an hour drive to you or so, and those that are coming to you from overseas.

LW: So the emotional component for me that I observe is a lot different. Patients who already have children and are coming for gender selection and they are just choosing the gender that they want, they just… they feel that they have a better chance at getting pregnant, because they have already had children, so their expectations are very high. Their attitude is, well, it’s gonna work because we already have kids, and all we’re doing is we can get pregnant very easy, however, so we’re just coming in for gender selection. However. Y’know, these patients who have had children already, now they’re in their… probably 35 or older that are coming for their third or fourth child, and they want that gender. We do pre-testing on them and lo and behold, they do have an infertility issue because now they’re older and their pre-testing or their ovarian reserve testing shows that they do have diminished ovarian reserve, so it is going to be a little bit harder to get them pregnant. So with that said, the emotional component of those patients is or expectations are a lot higher than a patient that does not have children already that are going through fertility. This is mainly what I see as an observation, so dealing with those patients on an emotional level, and trying to let them know that they do have fertility issues is a lot… is really a lot more difficult, I think, than dealing with patients who have not had children. Because their expectations are a lot higher coming into this than a patient that has infertility issues.

GJ: And if the age and situation are similar, are there other nuances between someone who’s coming to you locally versus someone who’s coming from another country? I imagine that… how do you deal with the language barrier, for example?

LW: So, most of my patients I don’t have a language barrier, unless they’re like from France or Belgium. Most of the time, one of the two parties do speak English. So I haven’t really run across too much of a language barrier for patients coming over. The other barrier would be cultural. Learning how to deal with different patients from different cultures because they do things a lot differently. That is an education all in itself. Sometimes you don’t deal with the wife, you deal only with the husband, because that’s their culture. Learning how to do that was a little bit difficult, because I think I have it down now. I do learn a few new things along the way, but that was a very interesting lesson coming in to doing international cases.

GJ: That’s something you probably wouldn't necessarily consider, too, is there even any training for that? Is that something you have to learn as you go?

LW: Yeah, there’s no training, I mean, yeah, just kind of learn as you go. There are cultural differences between how husband and wives react with each other and what is expected of the husband and wife in certain situations, especially infertility, I guess, or being able to communicate with both parties, sometimes I have put expectations on patients who are culturally diverse by saying that I must at least have both parties on the phone so that the wife can hear what I’m saying, because sometimes I get emails from both parties because they’re not talking to each other. They’re pretty open to that, as long as I keep to the rule that I only direct my questions to the husband.

GJ: That sounds like probably a cultural difference that’s more the extreme. There’s probably other things, like how you maybe the small talk you make, or any other thing that might affect patient care. Are they typically finding you from their own search, or do they often come from an agency that could help facilitate this?

LW: For my patients, we have we do have liaisons in Australia, because we have a lot of patients in Australia. I’ve traveled there a couple of times, we have a lot of patients in the London area, I’ve traveled there to meet with patients, and to meet the physicians that help us as well as the nurses, so I have a pretty good rapport with a lot of clinics and physicians and nurses from all over the main areas where I deal with, which is really awesome, because I’ve been doing this now for probably about 10 years, so I’ve made a lot of connections and connections from connections and people who want to help us, even though it’s illegal in those particular countries or cities, which has made it a lot easier for me to get my pre-testing results and monitor patients over there. They’re usually monitored in their country and they just come over here for the procedures. So, I’ve developed those relationships and it works really well.

GJ: ANd those relationships aren’t easy to build, either. Do you have a set number of countries that you’re working within, and then someone else is coordinating for East Asia or Latin America or other parts of the world?

LW: Yeah, so we have a team that does strictly Chinese patients. They speak Chinese and there are liaisons that they work with to bring patients here, so they work with them over there. So that’s a whole separate entity for our practice, and it’s quite busy.

GJ: I’m painting a picture of how involved this is, because I think it would be easy to say, oh, could we see some more patients from country A, but there’s really a lot at play that has to do with things you’re managing. You’re physically going over to certain countries to build these relationships and you’re only one of the teams. There’s other people working with other parts of the world-- this is really involved.

LW: Because there’s a need for it. Their countries aren’t going to provide that service, so patients are going to travel to countries that will provide it.

GJ: And when you’re managing nurses that serve these patients, is there… are there nurses that work just with international patients as well, or are you coordinating among all the nurses so sometimes they see international patients, sometimes they see local patients.

LW; Sometimes, so we have a third-party coordinator, and she will do the out-of-country that are not Chinese third-party cases, and like I said, we have our coordinator that manages the Chinese population solely because of the language, and they do everything in their language. So I… my job is to do the rest of the country, which is the United States, because I do have people that come from other states to our center for gender, because it’s not offered in their state or local clinic, we also have very good pregnancy rates, so people want to come to us for that. They look us up online, because everything is out there now, and they may come to us solely because of our pregnancy rates. The more patients we see and the more patients we get pregnant, the better our pregnancy rates are gonna show. That brings a lot of people to our center. Clinics… people that I do coordination for, sometimes they come because I’m not going to be bragging on myself, but my name is on a lot of websites, and I have patients that just get in touch with me. They get my email and they get in touch with me, it’s just a matter of getting back to them in a timely manner, and the way I give them information, they decide to come to our clinic. And then they tell other patients, and a lot of it comes from word of mouth as well.

GJ: I hadn’t really considered that, that folks would come from other states, but that makes sense if they’re doing family balancing. Do you often find that they’re balancing boys because they have more girls, already, or vice versa?

LW: I think it’s more of a personal choice that… like I said, passing on the family name, a lot of people culturally want to have boys if they have all girls, but I think sometimes for women it’s a desire to have a girl, if they have all boys, and I think it’s a personal choice, but I do know that when they want to have that gender, they will do whatever it takes to get that gender.

GJ: That’s what surprised me when I was talking to a mental health professional in our field a few years ago, and she said, Griffin, you wouldn’t believe how many mothers of three boys-- and she mentioned of two or three boys, but I think she really emphasized three, but they really want a girl for their third or fourth child, and I think I hadn’t considered that before, I think when we think of sex selection, we think of more of the cultural especially for probably some countries that are more of maybe of a patriarchial culture, for lack of a better term, and hadn’t really considered that that would be something so common, but she said it really is.

LW: Yeah. Very common. I have a lot of patients come for females. If I had to weigh out, I’d say probably I get more females than male, maybe a little bit more.

GJ: Then… are there other folks that you have to manage to make sure that they don’t face burnout in treating these patients? In other words, is it not just nurses, are there other coordinators, are there other folks that correspond with international patients that you need to make sure that they’re not getting burned out or are there translators or are there other considerations personnel wise, with burnout or compassion fatigue.

LW: Yeah, of course, we have our front office people, they help us schedule either their follow up appointments if they have failed cycle, so they come in contact with those patients, and our new patient coordinator who initiates all of the information to get them in as a patient, to get all of their information, so they’re the first ones that actually deal with those patients. I would have to say the most daunting and probably the most second next to the nurse that’s coordinating the cycles would be the financial coordinators, those are the ones that have to speak to the patients and collect the money. Sometimes that’s a really hard thing when they also have to pay for airfare, and hotel accommodations, and activities-- my patients come here and they do a vacation. So some days they bring other family members so they can watch the kids they have already, right, while they’re going through their procedure, so it’s not only bringing themselves, they bring their kids, they bring their in-laws, or their sister, or whoever wants to come, and then they kind of do this and then in the days that they have free, they go and travel and do vacation things with their kids. Disneyland is a big spot, Las Vegas, San Francisco, San Diego, because we have so many things here to offer patients to come and do other things other than just go through treatment here, so, having to pay for all of that plus the cycle. And their meds. And everything else, it can be quite costly. Our financial people are the next ones who really get the burnout issue.

GJ: When you’re helping them with that, because this is what you got into the speaking part of things because of your managerial experience helping reduce compassion fatigue, helping reduce burnout- are people just people? Is it the same for financial coordinators as it is for the nurses? Or are there nuances between how you council and manage the two because they’re different roles.

LW: With financials, it’s a little bit tricky, because with financials, the cost is what it is, so patients either have the money or they don’t have the money, so… y’know… counseling the financial counselors would be about the same, and how to reduce stress, how to deal with those patients and have them not take things personally like you would do with your nurses. You never want to take anything patients do personally, because you have to remember that these patients are frustrated, they’re on a journey that is very delicate, and a lot of times our patients-- nurses deal with patients, patients are on hormones, and some patients have histories, they have a journey they have been on before they even got to you. They’re not going to be the same people they were before they started on their journey. And you’ll know this, because if you deal with some of these patients and you get them pregnant, they are a whole different person after they get pregnant. They… you know that fertility changes people, and sometimes not in a good way, and unfortunately we as nurses and our financial counselors have to deal with that on a daily basis. The best way to deal with that is to take care of yourself. You have to take care of yourself before you can take care of others, that's a general rule for any person, but in order to be able to take care of these patients and deal with these patient situations is to take care of yourself first. And then you can take care of others better.

GJ: So how do you properly set these expectations with patients that are coming from across the ocean so that that doesn’t get taken out on your staff, like… do people ever say, well, isn’t Lori going to pick me up from the airport? Or do they ever call you with things like, this hotel sucks? Or the cable’s not working in my hotel room? How do you set the expectations?

LW: I don’t get a lot of that, I don’t get a lot of that but however, setting expectations with your patients, I think, is very, very important, because if you don’t from the very first time you talk to them, they’re going to complain. Because they’re not going to feel like they’re getting the service they’ve been paying for. I tell my patients right off the bat, as far as emailing or how our communication is gonna go, emailing is the best. And I always tell them, if you need a phone call, because a lot of patients need a phone call, we need to set up an appointment so you don’t keep calling me and missing me and I keep calling back, because of the time difference. I tell my patients, I’m happy to do a phone call, but we need to set an appointment so we don’t miss each other. And I tell financials do the same thing, because if you keep missing a patient, their anxiety and their anger is just gonna get worse and worse and worse, and by the time you end up talking to them, they’re gonna be so unhappy, you’re not going to be able to settle them down. So… expectations in the very beginning, whether you’re seeing a patient that’s local or any patient, let them know how your clinic runs, let them know when you’re going to be able to get back with them, so they don’t keep calling all day long. Now sometimes that’s not gonna work, because you’re gonna have that patient who’s still gonna call you when you’re in clinic, and they’re gonna expect you to drop everything and get to the phone. I always let patients know when I’m gonna be contacting them or when I’m able to contact them, and that they would hear from me within a 24 hr period or sooner. I always check my emails, I have to 24/7 because of the time difference, getting reports back and things like that, but I tell patients I don’t contact on Sunday, because that’s my holy day.

GJ: Fair enough.

LW: So they pretty much understand that, and they tell me you need to have a day off. Some people do understand that. Some people do not. You have to kind of feel out your patients, know when you have to be a little bit more stern, and the thing is, to be honest, I think a patient respects you more if you call them on their stuff. If they’re not being nice to you, tell them, I’m trying to be nice with you, I’m trying to do what I can to help you, I don’t feel that you need to talk to me that way. You’re a person. You’re a human being. You shouldn’t have to take stuff like that.

GJ: Setting patient expectations could be an entire episode. Lori, what would you want to conclude with about the nexus between international patients, between the nurses that serve them and mitigating compassion fatigue so that you’re reducing dropout and burnout, what would you want to conclude about all the two of those things and the bridge between them that I haven’t asked you about?

Lw: We touched on taking care of yourself first, trying to recognize that you have compassion fatigue, and how you can do that is you know when you see a patient’s number or you get a phone call from a patient and you don’t want to take that call? Or you have to take a deep breath… you are getting into compassion fatigue. It can happen in all aspects of the practice,not just the nursing part, but financial, front office, anywhere or anyone who deals with the infertility patients. Find ways to reduce your stress at work, ask your employers to provide maybe a five-minute massage once a week for your employees, or managerial support is always the best when you can go to them and say, listen, we’re stressed out or we’re getting close to burnout and we feel that we can’t do good justice to our patients and get their support. Hopefully you’ll have it-- figure out ways in your office that you can reduce stress together for yourselves so you can all be on the same page and you can reduce that stress. You will be able to manage your patients better, you’ll be able to manage your personal life better, your home life better…

GJ: Great advice form a very experienced professional who is doing this in a very great role… Lori Whalen, thanks so much for coming on Inside Reproductive Health.

LW: thank you, Griffin, for having me… it’s been a pleasure.